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By Vardan Arora BY VARDAN ARORA Contents Defining death in the law Medical defination of death Legal defination of death Determination of death UDDA Brain Death American Academy of Neurology Guidelines for Brain Death Determination Biological death and signs of biological death Quality Care at the End of Life LIFE SUSTAINING TREATMENT Decisions regarding life-sustaining treatment Autonomy, obligation to treat, and medical futility Specific treatment guidelines ICU admission CPR Defining Death in the Law. The law recognizes different forms of death, not all of them meaning the end of physical life. Natural death- It is death by action of natural causes without the aid or inducement of any intervening instrumentality. Civil Death- It is used in some states to describe the circumstance of an individual who has been convicted of a serious crime or sentenced to life imprisonment. Such an individual forfeits his or her Civil Rights, including the ability to marry, the capacity to own property, and the right to contract. Legal death- It is a presumption by law that a person has died. It arises following a prolonged absence, generally for a prescribed number of years, during which no one has seen or heard from the person and there is no known reason for the person's disappearance that would be incompatible with a finding that the individual is dead (e.g., the individual had not planned to move to another place). Violent death- It is death caused or accelerated by the application of extreme or excessive force. Brain death- It is a medical term first used in the late 1960s, is the cessation of all functions of the whole brain. Wrongful death- It is the end of life through a willful or negligent act. Medical definition of Death Death the cessation of life i.e. permanent cessation of all vital bodily functions. For legal and medical purposes, the following definition of death has been proposed-the irreversible cessation of all of the following: (1) total cerebral function, usually assessed by EEG as flat-line. (2) spontaneous function of the respiratory system. (3) spontaneous function of the circulatory system. Brain death- Irreversible brain damage as manifested by absolute unresponsiveness to all stimuli, absence of all spontaneous muscle activity, including respiration, shivering, etc., and an isoelectric electroencephalogram for 30 minutes, all in the absence of hypothermia or intoxication by central nervous system depressants. Called also irreversible coma and cerebral death.― N.B- Electroencephalography (EEG) is the recording of electrical activity along the scalp Legal Definition Of Death . An individual, who has sustained irreversible cessation of all functions of the entire brain, including the brainstem, is dead (a) In the absence of artificial means of cardiopulmonary support, death (the irreversible cessation of all brain functions) may be deter•mined by the prolonged absence of spontaneous circulatory and respiratory functions. (b) In the presence of artificial means of cardiopulmonary support, death (the irreversible cessation of all brain functions) must be deter•mined by tests of brain function. Determination Of Death In an era of rapid technological change, it is not unusual for technology to overcome medical, social and legal commonplaces. One instance of this is the legal standard for determining biological death. Advances in medical techniques and equipment have made it necessary to re-evaluate traditional legal standards for declaring a human being dead. Such standards are necessary not because of death itself, but because of the effect in the law of the biological fact of death. Determinations of death are also important in establishing the property relationships that arise through inheritance and devise. They are important in tort law to actions in wrongful death and survivor's action. The standards for determining death are not much of a problem for the deceased, but they are important to the living, who may be favored or disfavored The Uniform Law Commissioners (ULC) created the Uniform Brain Death Act in 1978 in an effort to clear up the legal ambiguity that had arisen over the question of determining death. It was plain that legal recognition only of traditional criteria—which rely on measuring cessation of respiration and circulation—would no longer suffice. Clearly the brain, as the center of the human body, is its most important organ. Its irreversible functioning should be accepted as death. Direct detection of loss of brain function is a product of very modern technology. The Uniform Brain Death Act simply established that the "irreversible cessation of all functioning of the brain, including the brain stem" is death. It then prescribed that determination of death be made in accordance with "reasonable medical standards." The ULC assumed that the traditional criteria would stand automatically alongside the brain-death standard described in the uniform act, and so did not mention those criteria in the act itself. But this omission proved confusing for states trying to adopt comprehensive legislation on the subject. The ULC corrected the situation in 1980 by replacing the act with the Uniform Determination of Death Act (UDDA). UNIFORM DETERMINATION OF DEATH ACT This Act provides comprehensive bases for determining death in all situations. "Uniform Determination of Death Act" developed jointly by the National Conference on Commissioners of Uniform State Law, the American Medical Association and the American Bar Association, approved October 19, 1980 and February 10, 1981. DEATH AS PER UDDA An individual who has sustain •either irreversible cessation of circulatory and respiratory• functions, or irreversible cessation of all function of the entire brain, including the brain stem, are dead. A determination of death must be made in accordance with accepted medical standards. Brain Death Brain death is the irreversible end of all brain activity (including involuntary activity necessary to sustain life) due to total necrosis of the cerebral neurons following loss of brain oxygenation. It should not be confused with a persistent vegetative state. Even after brain death, the working of the heart might continue at a slow pace, but there will be no respiratory effort. Brain death, either of the whole brain or the brain stem, is used as a legal indicator of death in many jurisdictions. American Academy of Neurology Guidelines for Brain Death Determination Establish irreversible and proximate cause of coma. Achieve normal systolic blood pressure. Perform 2 neurologic examinations Absence of brainstem reflexes. Apnea Test Ancillary tests Biological Death 1. The death caused by degeneration of tissues in brain and other part is called biological death. 2. Most organs become dead after biological death. 3. These organs can not be used for organ transplantation. Signs of biological death Cessation of breathing Cardiac arrest (no pulse) Pallor mortis, paleness which happens in the 15–120 minutes after death Livor mortis, a settling of the blood in the lower (dependent) portion of the body Algor mortis, the reduction in body temperature following death. This is generally a steady decline until matching ambient temperature Rigor mortis, the limbs of the corpse become stiff (Latin rigor) and difficult to move or manipulate Decomposition, the reduction into simpler forms of matter, accompanied by a strong, unpleasant odor. “Quality care at the end of life is what we wish for” A guiding philosophy of medicine is that the health and well being of the individual patient is of paramount consideration. There is a long-standing tradition in medicine that physicians must do everything medically possible to keep a patient alive. It is important that physicians understand and personally acknowledge that death is an acceptable outcome of care in certain circumstances, and that in many situations treatment cannot prevent death. Physicians should aim to provide their patients with care that fulfills the goals identified above, is compassionate and respectful, and allows patients to experience as dignified a death as possible. Dying patients may have last wishes relating to many issues other than treatment. Physicians should endeavour to honour the last wishes of patients wherever it is possible to do so, as respect for the autonomy of the patient must continue, to the extent clinically, physically, and legally possible, to the end of life. Quality Care at the End of Life Research and experience show that patient goals for quality end-of-life care generally include the following: Medical care: 1. Management of pain and other distressing symptoms; 2. Avoidance of unnecessary prolongation of dying; 3. Facilitation of clear decision-making and communication. Personal issues: 1. Treatment with respect and compassion; 2. Preservation of dignity; 3. Affirmation of the whole person; 4. Opportunity to address personal concerns; 5. Achievement of a sense of preparedness, control and meaning; 6. Preparation for death; 7. Achievement of closure. Relationships: 1. Strengthening of relationships with loved ones; 2. Relief of unnecessary burdens on others; 3. Contribution to others and continued participation and active involvement in social interactions, to the extent possible. LIFE -SUSTAINING TREATMENT Life-sustaining treatment is any medical intervention, technology, procedure, or medication that forestalls the moment of death, whether or not the treatment affects the underlying life-threatening diseases
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